Nutrition of Infants and Young Children in Poland – Pitnuts 2016

Abstract The study evaluating the feeding practices and the nutritional status of children aged 5 to 36 months in a general, Polish, representative population (n=1059) was carried out from May to July 2016. The aim of this study was to evaluate the feeding practices in children aged 5 to 36 months with regard to models of safe nutrition on the basis of the outcome of the population study performed in 2016. The data obtained show that the feeding practices in children in their first year of life do not meet the guidelines presented in the model of safe nutrition, particularly in matters of timing of complementary feeding introduction and food choice. The analysis of nutrient profile in toddlers’ diets indicated the differentiated energy and protein intake is significantly higher than population norms (EAR/AI). It is necessary to modify the nutrition of infants and young children through a better selection of products. Nutritional practice should always be monitored and modified according to the model of safe nutrition as part of medical nutritional counselling. More educational efforts are required to increase the awareness of the relation between the diet and nutritional status of young children among healthcare professionals.

INTRODUCTION e adequate nutrition of young children plays a crucial role in their optimal mental and physical development. is happens due to the reduction of risk for several diseases, including respiratory and digestive tract infections, as well as diet-related diseases, such as obesity, type 2 diabetes mellitus and cardiovascular disease [1][2][3]. Nutrition a ects the maturation and normal functioning of all systems of the child's body during the entire developmental period. It applies especially to the so-called critical periods, including the prenatal period and the rst two years of life [1].
Epidemiological observations and clinical trials concerning the impact of nutrition on the nutritional status indicated that incorrect nutrition, including inadequate pro le of nutrients in the child's diet, leads to disorders of the nutritional status and increases the risk of nutritional de ciencies [1,[4][5][6][7][8][9]. Four basic elements describing the rules of adequate nutrition have been identi ed in the models of safe nutrition, which should be understood as a system of nutritional recommendations developed on the basis of objectivised studies in the eld of medical nutrition. ese include: the organisation of the meals/eating frequency, selection of products in daily diet, energy and nutrient intake meeting the child's requirement, and other factors, including cultural patterns, familial, environmental and behavioural determinants, dietary habits, as well as physical activity [10].
e Polish standard of feeding children in their rst year of life (tab. I), which was developed in 2014 and modi ed in 2016 by a group of experts appointed by the national consultant in paediatrics, promotes breastfeeding and presents guidelines for feeding breastfed and nonbreastfed infants. It also reveals the suggested number and types of meals and the portion size the child should receive at a given age [5,[11][12][13]. e gradual accustoming the child to new products and encouraging it to try new avours and textures of food has a positive impact on the process of expanding the diet. e standard contains information on what kind of food the child should receive and when, yet it is the child, who decides how much he/she eats. e recommendations concerning post-infancy nutrition were developed based the objectivised scienti c studies evaluating the impact the nutrition in the rst two years of life has on the nutritional status of the child. e results indicate that it is most bene cial for the health and development of the child to continue breastfeeding until approx the. 12th month of life. Such feeding practice may also be used in the second and third year of life, as long as the mother and child wish. No upper age limit for breastfeeding has been established [13,14].
AIM e aim of this study was to evaluate the feeding practices in children aged 5 to 36 months with regard to models of safe nutrition on the basis of the outcome of the population study performed in 2016.

MATERIAL AND METHODS
e study evaluating the feeding practices and the nutritional status of children aged 5 to 36 months in a general, Polish, representative population (n=1059) was carried out from May to July 2016. e trial was performed as part of project No. 161/2016 entitled "Comprehensive evaluation of diet of children aged 5 to 36 monthsnation-wide Polish trial 2016", (pol. "Kompleksowa ocena sposobu żywienia dzieci w wieku od 5 do 36 miesiąca życia -badanie ogólnopolskie 2016 rok") nanced by the Nutricia Foundation. e sample selection and parents/caregivers enrolment was performed by the research provider (TNS Polska). e children were randomly selected for the study using personal identi cation numbers (PESEL). e subjects came from all over Poland, so that appropriate territorial representativeness was obtained. Two subgroups were distinguished -children in their rst year of life (n=447) and children in their second and third year of life (n=612). e nutritional status was evaluated based on anthropometric features and indices -body weight [kg], body length/height [m] and body weight-for-height ratio standardized according to the reference WHO growth charts [15]. e anthropometric measurements were performed by the medical personnel or trained interviewers/dieticians with regard to the selected methodology [15,16]. e feeding practices were evaluated by the questionnaire method (original questionnaire, including 3-day record of children's diet carried out by the parents/caregivers according to the directions given). Based on the diet records we estimated the consumption of the products and the nutritional value of the diets was calculated using the "Dieta 5" nutritional computer programme [17,18]. e results obtained were compared with age-adjusted nutritional recommendations -for infants aged 5-12 months and children aged 13-36 months [19]. e distribution of variables was analysed and the appropriate descriptive statistics were calculated (medians and interquartile ranges).

Study group characterisƟcs
ere were 50.6% of boys and 49.4% of girls in the subgroup of children aged 5-12 months (n=447), whereas the number of boys and girls in the 13-36 months subgroup (n=612) was equal.
e Table II presents the study group characteristics. Most of the children lived in cities. eir parents had mostly higher education and it was the mothers who had higher education more frequently.
Infancy e nutritional status of the children was evaluated based on the standardized weight-for-height ratio with regard to cut-o points established by the WHO [15]. e body weight of 67.6% of the infants was normal (the value of the analysed ratio ranged from -2SD to +1SD); 17.9% of the infants were overweight or at risk of becoming overweight, whereas 14.5% showed underweight (tab. III).  e study on nutritional practices in infants aged 7-12 months (the children aged 5 and 6 months were excluded, as it was uncertain whether they would still be exclusively breastfed) revealed that 54.1% of them were breastfed in the rst 6 months of life, whereas the proportion of children exclusively breastfed in that period was 5.9%. Infant formula was introduced in the rst month of life in 27.3% of infants. Table IV presents the proportion of children who received di erent food products in the initial phase of complementary feeding introduction. A signi cant number of parents (61.1%) started to expand the diet of their child before the h month of life. Water and teas for infants were the rst non-dairy products to be given to drink, followed by gluten-free baby cereals, fruit juices and fruit and vegetable puree. e diet of only 30.2% of the infants was expanded according to the recommendations, i.e. between 17 and 26 weeks of life (5-6 months of life).
Children in their second 6-month period of life received a varied diet in terms of food selection, its texture and energy value. Almost two-thirds (61.3%) of the children received meals cooked separately for them and 27.5% ate the same as the entire family every day or at least 2-4 times a week. Mothers used ready-to-serve foods intended for infants and young children (baby food). Almost 90% of the children received such products every day or at least 2-4 times a week. Most frequently it was infant formula and baby cereals. e data obtained show that the feeding practices in children in their rst year of life do not meet the guidelines presented in the model of safe nutrition, particularly in matters of timing of complementary feeding introduction and food choice.
PosƟnfancy e body weight of 67.8% of the children aged 13-36 months was normal and 4.1% of children were underweight (tab. V). e high proportion of overweight children and those at risk of being overweight (28.1%) is noteworthy.
Approx. 10% of the children aged 13-36 months were still breastfed. According to the statement of the mothers, the average number of breastfeeding episodes was 6, including 2 at night. e average number of meals consumed by children during the day was at least 5. What is noteworthy is the signi cant proportion of children receiving di erent sorts of snacks between the main meals (tab. VI). e adequate arrangement of meals received by the children during the day ensures the child receives appropriate energy supply and prevents nutritional mistakes from occurring. Young children should receive 4-5 meals per day: 3 larger and 1-2 small ones but some of them may require a larger number of meals, yet smaller in volume.
Table VII presents the comparison of an average daily food ration of the children aged 13-36 months with model food ration. We observed insu cient consumption of milk and fermented milk beverages, vegetables and fruits as well as sh, which results in an unbalanced nutrient pro le of the toddlers' diet. e share of food products of special nutritional purpose, i.e. ready-to-serve food intended for infants and small children depended on the age of the children. Half of the children in the second year of life consumed a junior formula and baby cereals, one-third ate fruit purees and desserts and one-quarter of the group received readyto-eat soups or dishes every day or at least 2-4 times a week. e diet of children in the third year of life was mainly the family diet with a signi cant share of wheat bread, pasta and breakfast cereals, as well as milk, fruit yoghurts and dairy desserts, poultry and cured meats, vegetables and fruits (tab VIII). e analysis of the nutrient pro le in toddlers' diets indicated the di erentiated energy and protein intake was signi cantly higher than population norms (EAR/ AI) (tab. IX). In 74.8% of children the share of energy originating from sucrose was greater than recommended (% of energy from sucrose <10). e diet of almost every child contained a shortage of long chain polyunsaturated fatty acids (LCPUFA), vitamin D and potassium (99.0%, 94.4% and 87.4% respectively). Insu cient intake of fats, vitamin E, calcium and bre was observed in every second child, whereas a shortage of energy and iodine occurred in almost every third child. e data obtained con rm the signi cant diversity of the nutritional value of diets, which in turn indicates the need for their monitoring. Insu cient intake of long chain polyunsaturated fatty 15. Yoghurt

DISCUSSION
According to the guidelines of the World Health Organisation (WHO) and European nutrition societies, exclusive breastfeeding is the optimal method of feeding infants for 6 months followed by the appropriate complementary feeding introduction in the second half of their rst year of life [11,12,20,21]. Breastfeeding ensures that all the nutritional requirements of the child are met and optimally stimulates his/her development. e qualitative and quantitative composition of mother's milk is ideally adjusted to the requirements of the infant. Apart from vitamin D and K, this applies to all nutritional elements, including proteins. It was shown that breastfeeding of babies from their birth till the age of 2 years is associated with a lower intake of protein and reduced risk of being overweight later in life, when compared to formula-fed children [4]. e model of safe infant nutrition emphasises the fact that exclusive breastfeeding is an optimal feeding method in the rst six months of life, whereas nutrition during the second half of the rst year of life should be based not only on breastfeeding but also on incorporating complementary foods according to recommendations [10,20].
In the rst 6 months of life 54.1% of infants from the studied group were breastfed, including 5.9% exclusively. e data obtained are similar to those gathered during epidemiological studies carried out by other authors [14]. e studies performed in 2014 evaluated the nutrition of infants (n=1679) and revealed that 38% of them were breastfed in their sixth month of life, 4% of whom exclusively [22]. ese data di er from the results of previous studies performed in Poland and other European countries, which indicated a greater percentage of exclusively breastfed children (13-14%) [14,23]. e question remains, however, why despite the widespread promotion of natural feeding presented during antenatal classes and with the use of di erent educational forms − the rate of breastfeeding women remains on a similar level. is issue requires separate studies.
Since the sixth month of life natural feeding or that carried out with the use of infant formula no longer provides an adequate supply of energy, protein, iron, zinc and some vitamins. erefore, the introduction of complementary foods is necessary. According to current recommendations, it is considered that complementary foods should be introduced no sooner than in the 17th   week of life, but no later than in the 26th week of life [21]. According to the ESPGHAN guidelines, exclusive or full breastfeeding should be promoted at least until the end of the fourth month of life (17 weeks), whereas exclusive or predominant breastfeeding for approx. six months of life (26 weeks) [21]. It is recommended that complementary foods ( uids and solid foods other than mother's milk and infant formula) should not be introduced before the age of 4 months and delayed beyond 6 months. e diet should be supplemented with products of diverse texture and taste, including green vegetables with a bitter taste. Breastfeeding should be continued alongside with the introduction of complementary foods. Small amounts of cow's milk should be used to prepare complementary foods, yet it should not be used as the main milk product until the age of 12 months. Potentially allergenic food may be introduced when the complementary feeding is commenced (but not before the h month of life), yet such practice requires supervision by a specialist. Gluten-containing products may be introduced between the 4 and 12th months of age. Nevertheless, it should be noted that their amount should be limited during the rst few weeks. All infants should receive iron-forti ed foods (e.g. cereal products) and food being a natural source of iron (meat). Adding salt and sugar to the products and meals intended for children should be avoided, as well as drinking sweet beverages. e consumption of fruit juices should be limited. Vegan diets require the supervision of a paediatrician and/or dietician and appropriate supplements. e parents should be aware of the health consequences of such a diet. Parents' alertness to nutritional requirements of their child, signalled as a feeling of hunger or satiety, is equally important. It has been proven that such a practice is important from the nutritional, developmental and health point of view, because it is associated with a signi cant reduction of the risk of contracting infectious, especially gastrointestinal and respiratory, allergic and autoimmune diseases. Moreover, it has no negative impact on the rate of growth, body composition and does not increase the risk of becoming overweight or obese [21].

Milk and milk products
In the studied group 61.1% of the children received complementary feeding earlier than it is recommended (before the 5th month of life) and only 30.2% of the infants received their rst non-dairy foods (baby cereals, vegetable and/or fruit purees, juices, infant teas) between the 17th and 26th week of life. ese results unequivocally indicate that almost two-thirds of the mothers of the studied children did not know the optimal age for the introduction of complementary foods. erefore, it is necessary to monitor the feeding practices of infants and to provide nutritional counselling for the mothers of young children alongside routine inpatient paediatric care.
e energy and nutrient intake in children's diet should meet nutritional recommendations [19]. e protein requirement of children was estimated at approx. 1 g/kg body mass, yet it should not exceed 15% of the total recommended energy intake (1000 kcal/day). Fats should deliver 20-35% of total energy, so that they cover the energy expenditure of the child, including the part required for growth. e intake of fat of adequate quality is very important as well, including the sources of fatty acids, especially long chain polyunsaturated fatty acids (LCPUFA). Carbohydrates should account for 55-60% of energy. e amount of added sugars should be limited (less than 10% of total energy). Products delivering complex carbohydrates should be preferred in the diet of children. Recommended  for calcium in a 1-3 year old child is 700 mg/day, while the population estimated average requirement (EAR) is 500 mg/day. According to medical standards, a child requires approx. 15 µg (600-1000 IU) vitamin D 3 /day [5,19,24]. When it comes to the group of children over 1 year old, it is worth noticing that 10% of this group were still breastfed and 43.3% were receiving junior formula, whereas the proportion of children drinking such formula decreased signi cantly a er the 18th month of life. e share of junior formula in the nutrition of children aged 1 year and older signi cantly impacts the nutritional value of their diet [25]. e adequate supply of energy and nutrients, especially proteins, DHA, vitamin D, iodine and iron still signi cantly in uences the processes associated with the metabolic and nutritional programming in a child, and reduces the long-term risk of diet-related diseases, including obesity [25]. e nutrient pro le in the analysed diets of children did not meet the recommendations. e results showed insu cient intake of many nutrients important for the normal development of the child, i.e. LCPUFA, vitamin D and potassium. Furthermore, the increased risk for energy, fat, bre, vitamin E and calcium de ciency was observed in the diet of almost every second or third child. Such results prove the poorly  diversi ed selection of products used in nutrition of the youngest children. e research of other authors, who analysed the quantitative and qualitative composition of children's diets, revealed a similar trend [8,9,[26][27][28]. ese data con rm that it is necessary to popularise the model food ration for children aged 1-3 years among parents. It seems that the results obtained should provide the basis for reformulation of the quantitative and qualitative composition of dietary products/food intended for infants and young children. e population study conducted on the group of children aged 5 to 36 months indicates the problem of excessive intake of sucrose and salt in children's diet. e WHO mission for 2015-2020 emphasises the necessity to reduce the amount of such nutrients in children's nutrition [29]. erefore, it is necessary to develop such forms of educational impact for the parents of young children, which will eventually change their attitude towards healthy nutrition.